Fillable MDR Tracking No - tdi texas

Description
Texas Department of Insurance, Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 Austin, Texas 78744-1609 MEDICAL DISPUTE RESOLUTION FINDINGS AND DECISION PART I: GENERAL INFORMATION Type of Requestor: (x) Health Care Provider Requestor s Name and Address: ( ) Injured Employee ( ) Insurance Carrier MDR Tracking No.: Claim No.: Injured Employee's Name: Date of Injury: Employer's Name: Insurance...
Fill & Sign Online, Print, Email, Fax, or Download
Fill Online
  • Fill Online
  • eSign
  • eFax
  • Email
  • Add Annotation
  • Share
Fill Online
Rate This Form

4.0

Satisfied

60

 Votes